Guide to Children's Dental Care in Medicaid
Guide to Children's Dental Care in Medicaid
By: Department of Health and Human Services
Date: October 2004
Source: Department of Health and Human Services USA. "Guide to Children's Dental Care in Medicaid." Available online at 〈http://www1.cms.hhs.gov/MedicaidEarlyPeriodicScrn/Downloads/EPSDTDentalGuide.pdf〉 (accessed January 5, 2006).
About the Author: The United States Department of Health and Human Services (DHHS) is a federal agency tasked with protecting the health and welfare of all persons residing in the United States, and with assuring that they receive, or have access to, all necessary human services. DHHS is charged with oversight or administration of more than three hundred discrete programs. Although it is a federal agency, it works very closely with state and local governments to assure the adequate provision of public, and public health, services.
There are written (on papyrus scrolls) descriptions of primitive attempts at dentistry dating back to 3700 BCE. Diseases of the mouth, teeth, and gums predate history: evidence of dental caries (tooth decay, or dental cavities) were found in mummies in the pyramids of Giza. Little has changed through time, and the most common ailments of the mouth are still related to dental caries and gum disease (periodontal disease).
The earliest dentists to mention preventive dentistry (in concept, not in terminology) in their scholarly writings were from Bologna, Italy. In 1400, a dentist named Giovanni de Arcoli, advised his patients against the excessive eating of sugary sweets, told them to avoid foods at the extremes of temperature (very cold or very hot), and was an advocate of keeping the mouth, gums, teeth, and oral cavity clean. The toothbrush was invented in China, just before the start of the sixteenth century. In 1766, the British dentist Thomas Berdmore published a textbook in which he stated that there existed a relationship between the ingestion of excessive amounts of sugar and the development of dental problems. In 1819, Levi Spear Parmly published a book entitled A Practical Guide to the Management of the Teeth, in which he described a technique for flossing the teeth with waxed silk thread. He stated that this, along with daily cleaning of the teeth using a brush and tooth cleaner, would completely prevent the development of dental caries and periodontal disease. Economics was a significant factor hampering the widespread practice of adequate oral hygiene: dental brushes were very costly, tooth cleaners and silk thread were prohibitively expensive. It was not until the development of cost-effective nylon products during World War II that toothbrushes and dental floss became affordable for the general public. Even then, few people found the concept of flossing after meals viable.
Until the 1940s, dentistry was viewed primarily as a reactive and healing-oriented profession: people went to the dentist only when they were in pain or had difficulty eating. American culture did not have a norm for preventive dentistry. The first large-scale public health efforts at preventive dentistry concerned the introduction of fluoride into public water supplies. The American Dental Association determined that the regular drinking of fluoridated water could decrease the likelihood of developing cavities by up to 40 percent. It was also discovered that the ingestion of fluoride could reverse early signs of dental decay.
Tooth brushing after meals was well-known to clean teeth, and to remove decay-causing oral bacteria. The addition of fluoride to commercially available toothpastes bolstered the preventive effects of brushing at least twice daily. Components of modern oral hygiene, practiced in the home setting are: brushing teeth after meals, flossing at least once daily, eating few processed sugar-laden foods, limiting between meal and late-night snacking, and eating healthy foods.
Modern preventive dentistry has several components, differing according to age group. For very young children, the ingestion of fluoride, either through the commercial water supply or in the form of daily oral supplements or oral rinses and bolstered with semi-annual applications of fluoride directly to the teeth, is recommended. In addition, a thin plastic coating called a sealant is often painted on the primary teeth of young children, particularly on the biting surfaces of the molars. This is believed to diminish the likelihood of decay, and to aid in the retention of primary teeth until the adult teeth are ready to descend naturally. During the last two decades of the twentieth century, significant attention was focused on the tendency of babies who were put to sleep while drinking a bottle (which they were permitted to retain) to develop decay in the front teeth. As a result, the use of a bottle after the first year, as well as the use of milk or formula as a sleep aid, was strongly discouraged. Parents were encouraged to use a soft cloth to wipe out babies' mouths after they ate or drank, even prior to the eruption of teeth. A first visit to the dentist has been recommended as soon as most of the first teeth have descended, followed by routine twice-yearly appointments.
It is now considered a standard practice to have twice yearly dental visits, with thorough examinations, bitewing x rays annually, full mouth x rays every two-to-three years, and semi-annual teeth cleaning performed by an oral hygienist.
In the mid-1970's, the Centers for Medicare & Medicaid Services (CMS) (formerly the Health Care Financing Administration), published "A Guide to Dental Care: EPSDT/Medicaid." That guide was intended to complement, supplement and expand upon policy information contained in CMS' State Medicaid Manual (SMM)…. The guide was developed for the use of state Medicaid agencies, dental and other health care providers, and national, state and local policy makers involved in organizing and managing oral health care for children under Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service….
Over the past two decades dramatic changes have occurred in dental science and technology, in public policy approaches to dental care delivery, and in the Medicaid program itself….
Consequently, CMS issued a contract to the American Academy of Pediatric Dentistry (AAPD) for the purpose of reviewing the original Guide and developing a revision for use by stakeholders concerned about children's oral health in Medicaid….
The Guide is intended to serve as a resource of current information on clinical practice, evolving technologies and recommendations in dental care. The guide is not intended to change current Medicaid policies, nor is it intended to impose any new requirements on states….
DENTAL CARIES IN U.S. CHILDREN
Among the many dental conditions affecting children, dental caries (tooth decay) is the preeminent concern in the context of Medicaid services because of their substantial prevalence in the low-income population. Tooth decay continues to be the single most common chronic disease among U.S. children, despite the fact that it is highly preventable through early and sustained home care and regular professional preventive services.
The prevalence and severity of tooth decay in U.S. children has changed considerably over the past several decades. Once a disease of nearly universal occurrences for nearly all children, tooth decay is now generally distributed in the pediatric population to the point that roughly 80 percent of caries in permanent teeth is concentrated in 25 percent of U.S. children. Also, minority and low-income children disproportionately experience decay in their primary teeth. The high-risk, high-prevalence, high-severity group, which currently represents nearly 20 million children, is largely comprised of low-income children (nearly all of whom are eligible for Medicaid or SCHIP), with higher levels of caries found in African-American and Hispanic groups at all ages.
Dental caries generally is considered to be reversible or capable of being arrested in the earliest stages through a variety of proven interventions. Beyond the early stages, the decay process generally tends to advance and become more difficult and costly to repair the longer it remains untreated. Hence, treatment initiated early in the course of dental caries development will almost always be easier for both child and dentist, less expensive, and more successful than treatment begun at a later time.
Prevalence and Risk Data from recent national surveys reaffirm the persistence of dental caries as the single most prevalent chronic disease of childhood. Roughly half of U.S. children experience dental caries by age nine; and the proportion rises to about 80 percent by age 17. Overall, national epidemiological surveys show that nearly one-in-five (18.7%) U.S. children two to four years of age have visually evident tooth decay…. Tooth decay is closely tied to socioeconomic levels, with children from low-income families more likely to develop caries. Preschoolers in households with incomes less than 100% of the federal poverty level (FPL) are three to five times more likely to have cavities than children from families with incomes equal to or above 300 percent of the FPL. The Third National Health and Nutrition Examination Survey (NHANES III) found visible decay in 30 percent of two to five year-old children in poverty and 24 percent of near-poor children (100%-200% of the FPL). Caries was present in only 12 percent of middle-income youngsters and 6 percent were from families with the highest income levels.
Severity Within the highest-risk, lowest-income group, roughly one-quarter or four to five million children experience more severe levels of the disease, often with associated pain, infection and disruption of normal activities. These children generally acquire the disease early in childhood and often present as infants with multiple teeth in advanced stages of decay (a condition now referred to as "early childhood caries" or "ECC," and known previously as "baby bottle caries"). Children living in households below 200 percent of the poverty level—roughly half of U.S. children—have three and one half times more decayed teeth than do children in more affluent families.
Unmet Treatment Needs Dental care is the most common unmet treatment need in children. Lower-income children have more untreated dental disease than more affluent children who obtain care on a regular periodic basis. Reasons for this disparity include the fact that low-income children are more likely to experience dental disease and frequently only access care on an episodic or urgent basis when decayed teeth cause pain or swelling. NHANES III, the most recent national survey, found that nearly 80 percent of the decayed teeth of poor two to five year olds and 40-50 percent of the decayed permanent and primary teeth in six to fourteen year-olds were unfilled (untreated).
Consequences The consequences of severe, untreated dental disease and poor oral health in millions of American children are evident in many dimensions. Biologically, untreated dental disease can lead to pain, infection and destruction of teeth and surrounding tissues with associated dysfunction. Untreated tooth decay may lead to delayed overall development among young children affected with severe forms of the disease. Dental diseases have been shown to be associated with systemic health conditions. Socially, affected children have problems with school attendance and performance, and are often stigmatized because of their appearance. Potential consequences to the health system as a result of poor dental health care would include: frequent visits to emergency departments (often without definitive resolution of the presenting problem); hospital admissions; and treatment provided in operating rooms for conditions that are either largely preventable or amenable to less costly care had they been treated earlier.
CONTEMPORARY DENTAL CARE FOR CHILDREN
Emphasis on Early Initiation of Oral Health Care Science has provided a clear understanding that tooth decay is an infectious, transmissible, destructive disease caused by acid-forming bacteria acquired by toddlers from their mothers shortly after their first teeth erupt (generally around six months of age). In its early stages, the effects of dental caries are largely reversible through existing interventions (e.g., fluorides) that promote replacement of lost minerals from the outer layer of the tooth (enamel). These findings, combined with epidemiological data on the occurrence of tooth decay in infants and young children, suggest that true primary prevention must begin in the first to second year of life. This evidence also suggests that particular attention should be paid to the oral health of expectant and new mothers.
In early childhood there is tremendous growth and development of the face and mouth, with dentition-associated disturbances that may require the attention of dental professionals. Other common oral conditions of childhood (in addition to tooth decay) include: gingivitis and mucosal (soft tissue) infections; accidental and intentional trauma; developmental disturbances associated with teething or tooth formation; poor alignment of teeth or jaws; and craniofacial abnormalities (including clefts of the lip and/or palate). Additionally, parents frequently request information on a diverse array of concerns including: sucking habits; fluoride usage; tooth alignment; timing and order of tooth eruption; and discolored teeth….
Successful Models for Achieving Oral Health "Dental Primary Care"
Professional guidelines (and Medicaid statutory requirements) for addressing pediatric oral health needs are predicated on early and periodic clinical examinations to assess for evidence of pathologic changes or developmental abnormalities, diagnoses to determine treatment needs, and follow-up care for any conditions requiring treatment. These recurring periodic oral assessments ("dental check-ups") are generally coupled with routine preventive services (self-care instructions, fluoride applications, dental sealants, etc.) and increasingly seek to incorporate assessments of risk factors that elevate the likelihood of destructive changes if allowed to persist. This pattern of periodic assessments, preventive services, and necessary follow-up care also generally applies for adults, who collectively are more susceptible to the development of periodontal disease, oro-pharangeal cancers, and other soft tissue abnormalities. A large and growing proportion of the U.S. population that has adopted this pattern of care faces relatively few barriers to accessing services because of household income levels and/or private dental insurance. They enjoy unprecedented levels of oral health status. However, access for low-income children remains a challenge….
Critical Clinical Elements of Dental Services This section provides an overview of several critical clinical issues regarding children's dental services, as well as further elaboration of topics introduced in prior sections. Dental care includes diagnostic services, preventive services, therapeutic services and emergency services for dental disease which, if left untreated, may become acute dental problems or may cause irreversible damage to the teeth or supporting structures. Dental diseases and conditions of primary concern during childhood include dental caries (tooth decay) and problems or anomalies related to disturbances of growth and development. Periodontal diseases and other conditions affecting so-called soft tissues within the mouth and underlying bone, often related to systemic health problems, also affect oral health in a smaller percentage of children.
Because children remain at varying levels of risk for dental diseases and developmental disturbances, and because the best outcomes are achieved when these conditions are detected and treated early, periodic examinations at intervals commensurate with levels of risk are recommended for all children starting at an early age and continuing throughout childhood and adolescence. The often insidious onset of dental diseases require that practitioners responsible for children's oral health understand underlying disease processes and have the training, experience, and equipment necessary to accurately diagnose and manage common dental diseases and, when necessary, provide a range of therapeutic services to restore damaged structures.
As with nearly all health care related concerns, there is a direct relationship between socioeconomic status and likelihood of engaging in preventive dentistry (or preventive medicine). In America, there is also a clear association between racial and ethnic minority group membership and poverty. The poorer one is, the less likely she is to have either profitable employment or a job that provides adequate medical or dental insurance, and to have ready access to reliable transportation. In rural and frontier communities, the challenges are compounded by geography and demographics: few health care professionals choose to locate in areas of poverty and sparse population. Often, isolated areas lack either access to public transportation or a public transit system.
Although fluoridated water has been shown to be highly effective at strengthening tooth enamel and thereby reducing the likelihood of developing caries, only about half of the public water supplies in the United States utilize it. In areas where there is no fluoride in the water, the most impoverished people are likely to have the highest number of cavities, as well as the greatest incidence of emergency room visits for the treatment of pain associated with cavities, gum disease, dental abscesses, or oral infections. There is also a disproportionate relationship between poverty and poor diet (routine intake of low quality food, containing high concentrations of fats, preservatives, chemical additives, and processed sugars.
Individuals and families with limited income are significantly less likely to go to a dentist on a routine (non-emergent) basis than those whose incomes are well above the poverty level. Although many children and families living at or below the poverty level in the United States are entitled to receive Medicaid benefits, many do not apply. Of those who do obtain benefits, not all will be able to manage the requirements of well-child or preventive medical or dental visits. For many people living in poverty, particularly those who are geographically isolated, it has been virtually impossible to obtain dental (and medical) care unless it is an emergency. In part, this is because of the scarcity of dental providers who are willing to accept Medicaid patients. The public health system has been working to change this situation by increasing reimbursements for routine dental services (as well as urgent and emergent treatments), and attempting to streamline the cumber-some paperwork (claims) and administrative burdens of Medicaid providers. With ever-advancing technology, computer systems have become far more affordable for even the smallest of businesses, lending to the feasibility of electronic billing systems to further simplify and expedite the claims submission and negotiation processes. Several states have now passed legislation that prevents dentists (and some other types of health care providers) from being accepted as providers for private insurers (HMOs, PPOs, etc.); others are offering incentives such as location pay and loan forgiveness programs in order to attract qualified dental professionals to impoverished, rural, or frontier areas. The goal of the American Dental Association, as well as that of the American Public Health System (Medicaid, Medicare, etc.) is to guarantee access to excellent dental and medical care for all people, regardless of geographic location or socioeconomic status, in order to ensure "well" and preventive visits on a routine basis.
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